Fifty Shades of Mirtazapine

EL’s story

I have been taking Mirtazapine now for several years and have noticed two major changes since taking it, one my menstrual cycle has been effected and secondly my libido has increased.

My menstrual cycle has been quite erratic since starting Mirtazapine sometimes being completely absent one month to the next month being extremely heavy, other times I can get spotting in between. I have looked this up on the Internet and learnt that this is quite a common side effect when taking Mirtazapine. The worst part though is the mood swings and irritability that can last for several days before a period. I can just explode verbally at anyone over the slightest thing and feel terribly guilty afterwards. I have no patience at all when I feel like this. I also feel very weak and drained after a heavy period, feel very foggy headed and can feel very depressed and cry for no reason at all.

After several days to a week after my period I then sometimes get very strong urges for sex I just get so turned on, this I have never experienced before Mirtazapine and only felt this before in the company of a boyfriend in the right time and place. I can feel very sexual and turned on even when out and about, I could be in Tescos or anywhere and just get these sexual urges and find myself flirting with men. The only way to stop these urges is to mentally force myself to think of something more serious. It really is quite bothersome because you can’t just drop everything in the middle of the day to have some sex. The sexual feeling’s I’m getting can also cause me to have sexual fantasies which make’s things even worse still and then I feel as if I could just keep on having sex all night long and still not be totally satisfied. This may sound funny or even great to some people but it really can also be very disruptive, very inconvenient and very annoying. Too much of anything is not good or enjoyable anymore, its really getting me down.

Fifty shades darker

My first encounter with this issue was 20 years ago treating Erika who had post-traumatic stress disorder. Looking around for something that might help her, I stumbled on an article in the Journal of Military Medicine on the use of cyproheptadine as an aid to manage the flashbacks soldiers have as part of PTSD. I suggested this to Erika who was happy to try it.

Cyproheptadine has an extraordinary history. Like most early antidepressants, it is basically a tricyclic antihistamine. It was made by Merck and brought on to the market in 1960 as a weight gaining agent, just at a time when gaining weight was going out of fashion. They switched instead and marketed it on third world markets seemingly as an answer to malnutrition. This caused them terrible trouble. It was cited for many years as a great example of a Problem Drug and a telling example of bad company behavior.

It is an almost identical molecule to mianserin, which in the 1980s became the best-selling antidepressant in Europe. Mianserin essentially is mirtazapine.

What was Mona Lisa on?

She came back some weeks later saying that it didn’t help the flashbacks she was having. But she didn’t want to stop. There was a certain something about her smile that alerted to me to what might be going on. I checked and yes she said – this was really something. Made you feel sexy.

Made me feel sea-sick. The problem was I knew how she made a living. She was on the game. If this was going to increase her appetite for business, this might seem like a good thing now. Except back then at the height of the AIDs scare, my worry was she would get AIDs and the question was whether I would be to blame. A court of law didn’t bother me. It was living with myself that was the issue.

Fifty shades unfreed

I can readily imagine that medicines like this could do a huge amount of good. But as Notes on a Scandal outlines, they can cause serious problems. The book Notes on a Scandal by Zoe Heller tells the story of a schoolteacher, played by Cate Blanchett in the movie, who seduces a male pupil. Heller had been on Prozac and was a notable proponent of its use.

SSRI stories hosts close to thirty stories of female schoolteachers molesting younger male pupils. In most cases, SSRIs, like Zoloft, Paxil and Prozac kill libido but in a small number of cases – maybe one in ten – they can do the opposite. But these drugs also disinhibit, so even while killing libido for the most part, they can lead to disinhibited behavior and this may account for what happens to schoolteachers.

What happens can be very destructive, as I found out from a colleague, who had an attractive patient, Goldie, who on Prozac became dangerously promiscuous. She began craving alcohol, drank to extreme and had sex with anyone. She slept with cab drivers, was raped which she tried to report to the police but sabotaged it by telling them where to go, had sex with teenagers at a club while drunk. The police said they couldn’t do anything. No one was able to do anything for her unless she did something herself about it but she didn’t and was divorced by her husband, ended up with a much older man.

Compulsive sexual gambling

Goldie’s story is very reminiscent of the compulsive gambling and promiscuity on Efexor in Does Pfizer play Dice. Antidepressants can do this but dopamine agonist drugs used for Parkinson’s Disease are even more noted for this effects. One in six people on these drugs may have changes of behavior in the direction of promiscuity and compulsive gambling.

The drugs mess up your reward hierarchies. This is not simple disinhibition. Add in a switch in orientation to this and you have an extraordinary cocktail. Can a switch in orientation be simple?

Drugs and sex in the city

Several weeks ago we put out a News Release on the opening of the RxISK Sex Zone in which I noted that early use of the antidepressants in the 1950s had led to consistent reports of patients changing orientation on these drugs. There was a note of celebration back then for changes from homosexuality to heterosexuality but just the opposite switches are equally likely. I now know several such cases.

The response from colleagues has been they think it unlikely this can happen. I think switches like this or something people interpret as a switch do happen and they suggest the boundaries between our identities in many different domains are more fluid that we might like to think.

Can we base a claim like this on just a few stories? Switch the word story for narrative based medicine and everything looks different. Everyone forgets that good single case studies sit at the top of the evidence based medicine hierarchy – it’s the opinions of experts that sit on the bottom.

In elite recreational drug circles – among doctors – combining drugs like cocaine and ketamine (Calvin Klein) are done on the basis of stories from colleagues and personal experience. Doctors who when dealing with patients won’t move without the sanction of a clinical trial, when it comes to their own lives trust the evidence of their own eyes to make drug use like this safer than the gambling on clinical trials that underpins giving drugs to patients.

Change back to the word story and we have code that often means “we don’t want to scare patients from taking drugs”. But pharmaceutical companies market drugs by telling stories of wonderful successes and lives transformed – in one direction only. This will be picked up in the next post.

Comments

EL’s new drugs have clearly fired up her sexual turbines — I agree, not disinhibited her but have created desires where previously few existed. I’m baffled about the gays who apparently go straight on SSRIs. In my view, sexual orienation is something deeply biological, acquired at birth, and for a pharmaceutical agent to change it would be very surprising though not impossible.

Is there a pharmacology of fetish-sm? Clearly, drugs such as ethanol disinhibit, and open doors people previously didn’t know existed. But do they create doorways?

I take it you haven’t yet had any posts about the fetish-roleplaying scene? Its adepts are still deeply in the closet, far more buried behind the coatrack that the gays ever were. Here is what I might predict: Octavia reads Fifty Shades. She is also on Prozac. She is one of the atypical responders you mention, as the Prozac prompts her to leave her husband because he refuses to gratify her new sadomasochistic interests. She reports all this to Riisk couched as marital breakdown as a side effect of Prozac. It wasn’t that she was disinhibited. She had never been interested in sm before. It was Fifty Shades that created new doorways and Prozac that let her march through them. She’s very happy now in her leather jacket and boots as she stalks about looking for female subs to dominate.

I can’t disagree there’s something “deeply biological” about one’s basic sexual orientation – but behavior can be a lot more flexible. In repressive situations like prison or the army, there have always been men who start seeking out other men simply because no women are available. And I have known women to move from straight to gay, and back to straight, for social, emotional or even political and philosophical reasons. These transitions may not last a lifetime but they are real enough. Do people who can make them readily have a higher sex drive than the rest of us? Maybe. So maybe those who change from gay to straight (or vice versa) on SSRI’s are really just becoming bisexual on a drug that seems to raise their sex drive (rather than suppressing it, which is much more common). Does anyone know how these people’s new lives work out in the long term, like five years after the big change?

As for fetishes, etc. – SSRI’s are actually prescribed these days to reduce the urge for such behavior when it’s seen as compulsive and unhealthy. Peter Kramer’s Listening to Prozac described one man who took the drug for depression after his dad died. Supposedly his “normal” sex life was unaffected, but his lifelong interest in pornography vanished. The man had always seen his porn habit as part of his liberated, adventurous nature, but now started to wonder if it had been a disease. After all, a pill had “cured” it. (Like a lot of stories in that book, this one struck me as almost too good to be true.) So if this is an opposite, paradoxical reaction, maybe people just start searching the Internet or whatever for “something more” to absorb all that extra sexual energy. It reminds me of what you often hear from recovering cocaine addicts – many recall a very driven, compulsive pursuit of porn, sex clubs or other things they’d never thought much about before. It never sounds very liberating – just the opposite.

I can fully understand how a drug can disinhibit you. This happened to me when I was taking Enbrel/Entanercept to the point where I would have been so happy to have joined a Burlesque or Strip Tease club! (If I’d been 20 years younger I would probably have done it for real!)
My libido shot throught the roof – and I felt teriffic however the darker side of this is how do you contain it within ‘normal’ boundaries?
I can well understand how people go way off the rails when feeling something like this – I managed to soak my own libido up in various ways which didn’t cause a massive amount of damage but nevertheless- it is pretty scary to think what it could make people do!
Now I am no longer on the drug and feeling well -er – normal – I sometimes wish I could feel like that again but be in control of it!
Nope – I think I have enough libido normally- but never underestimate a drug’s ability to change your biological make-up and bring out the excesses in you!